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PART6 Treatment of Periodontal Disease

the root suggests the presence of a periodontal abscess,

Figure 30-32 Gingival abscess between upper lateral incisor and

canine.

An apical abscess may spread along the lateral aspect of the

root
to the gingival margin. However, when the apex and lateral
surface
of a root are involved by a single lesion that can be probed
directly
from the gingival margin, the lesion is more likely to have
originated as a periodontal abscess.
Radiographic findings are helpful in differentiating
between a
periodontal and a periapical lesion (see Chapter 31).
Early acute
periodontal and periapical abscesses present no
radiographic
changes. Ordinarily, a radiolucent area along the lateral
surface of

whereas
apical rarefaction suggests a periapical abscess. However, acute
periodontal abscesses that show no radiographic changes often
cause
symptoms in teeth with long-standing, radiographically
detectable
periapical lesions that are not contributing to the patients complaint. Clinical findings, such as the presence of extensive
caries,
pocket formation, lack of tooth vitality, and the existence of
continuity between the gingival margin and the abscess area, often
prove
to be of greater diagnostic value than radiographic appearance.
A draining sinus on the lateral aspect of the root suggests
periodontal rather than apical involvement; a sinus from a periapical
lesion is more likely to be located further apically. However,
sinus
location is not conclusive. In many instances, particularly in children, the sinus from a periapical lesion drains on the side of the
root rather than at the apex (see Chapter 51).
For more information on laboratory aids to clinical
diagnosis, please visit the companion
website at www.expertconsult.com.

References can be found on the companion

website at www.expertconsult.com.

SCIENCE TRANSFER
mouth series of radiographs taken within the last 2 years with
any needed updates is necessary to achieve a correct diagnosis
evaluation
and prepare the appropriate treatment plan.
that is recorded in the chart. This, at a minimum, includes
Periodontal screening and recording systems have little value
probing
in managing patients in a private practice because they do not
data on six surfaces on each tooth, as well as recording give sufficient specific data for individual patient treatment
gingival
planning.
recession and bleeding on probing. Other parameters
that need
to be recorded include mobility, furcation involvement,
mucogingival deficiencies, plaque scores, open contacts, and
examination
of functional occlusal relationships. A comprehensive
medical
and dental history must accompany the clinical
protocol. A fullAll patients should have a comprehensive periodontal

CHAPTER 31
Radiographic Aids in the Diagnosis
of Periodontal Disease
Sotirios Tetradis, Fermin A. Carranza, Robert C. Fazio, and Henry H. Takei

CHAPTER OUTLINE
NORMAL INTERDENTAL BONE
RADIOGRAPHIC TECHNIQUES
BONE DESTRUCTION IN PERIODONTAL DISEASE
Bone Loss
Pattern of Bone Destruction
RADIOGRAPHIC APPEARANCE OF PERIODONTAL
DISEASE
Periodontitis
Interdental Craters
Furcation Involvement
Refer to the

Periodontal Abscess
Clinical Probing
Localized Aggressive Periodontitis
Trauma from Occlusion
ADDITIONAL RADIOGRAPHIC CRITERIA (online only)
SKELETAL DISTURBANCES MANIFESTED IN THE JAWS
(online only)
DIGITAL INTRAORAL RADIOGRAPHY
ADVANCED IMAGING MODALITIES

companion website at www.expertconsult.com for additional content.

Some figures may be out of numeric order in this printed chapter.

adiographs are valuable for diagnosis of periodontal

disease,
estimation of severity, determination of prognosis,
and
evaluation of treatment outcome. However, radiographs
are
an adjunct to the clinical examination, not a substitute
for it.
Radiographs demonstrate changes in calcified tissue;
they do
not reveal current cellular activity but rather reflect the
effects of
past cellular experience on the bone and roots.

NORMAL INTERDENTAL BONE

Evaluation of bone changes in periodontal disease is based
mainly
on the appearance of the interdental bone because the
relatively
dense root structure obscures the facial and lingual bony plates.
The
interdental bone normally is outlined by a thin,

radiopaque line
adjacent to the periodontal ligament (PDL) and at
the alveolar
crest, referred to as the lamina dura (Figure 31-1).
Because the
lamina dura represents the cortical bone lining the tooth
socket, the shape
and position of the root and changes in the angulation of
the x-ray beam
produce considerable variations in its appearance. 15
The width and shape of the interdental bone and
the angle of
the crest normally vary according to the convexity of
the proximal

tooth surfaces and the level of the cementoenamel junction (CEJ)

of the approximating teeth.29 The faciolingual diameter of the bone
is related to the width of the proximal root surface. The angulation
of the crest of the interdental septum is generally parallel to a line
between the CEJs of the approximating teeth (see Figure 31-1).
When there is a difference in the level of the CEJs, the crest of the
interdental bone appears angulated rather than horizontal.

RADIOGRAPHIC TECHNIQUES
In conventional radiographs, periapical and bite-wing projections

offer the most diagnostic information and are most commonly

used
in the evaluation of periodontal disease. To properly and
accurately
depict periodontal bone status, proper techniques of exposure
and
development are required. The bone level, pattern of bone
destruction, PDL space width,33 as well as the radiodensity, trabecular
pattern, and marginal contour of the interdental bone, vary by
modifying exposure and development time, type of film, and xray
angulation.17 Standardized, reproducible techniques are required
to
obtain reliable radiographs for pretreatment and posttreatment
comparisons.16,24,31

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360

PART6 Treatment of Periodontal Disease

Prichard23 established the following four criteria to

determine
adequate angulation of periapical radiographs:
1. The radiograph should show the tips of molar cusps
with
little or none of the occlusal surface showing.
2. Enamel caps and pulp chambers should be distinct.
3. Interproximal spaces should be open.
4. Proximal contacts should not overlap unless teeth
are out of
line anatomically.
For periapical radiographs, the long-cone paralleling
technique
most accurately projects the alveolar bone level8 (Figure
31-2). The
bisection-of-the-angle technique elongates the projected
image,
making the bone margin appear closer to the crown; the
level of
the facial bone is distorted more than that of the lingual.
Inappropriate horizontal angulation results in tooth overlap,
changes
the shape of the interdental bone image, alters the
radiographic
width of the PDL space and the appearance of the lamina
dura,
and may distort the extent of furcation involvement (see
Figure
31-2).19
Periapical radiographs frequently do not reveal the
correct relationship between the alveolar bone and the CEJ. This is
particularly
true in cases in which a shallow palate or floor of the
mouth does
not allow ideal placement of the periapical film. Bite-wing
projec-

Figure 31-1 Crest of interdental bone normally parallel to

a line drawn
between the cementoenamel junction of adjacent teeth (arrow).
Note also
the radiopaque lamina dura around the roots and
interdental bone.

accounted for by x-ray angulation.

tions offer an alternative that better images periodontal bone levels.
For bite-wing radiographs, the film is placed behind the crowns of
the upper and lower teeth parallel to the long axis of the teeth. The
x-ray beam is directed through the contact areas of the teeth and
perpendicular to the film.35 Thus the projection geometry of the
bite-wing films allows the evaluation of the relationship between
the interproximal alveolar crest and the CEJ without distortion
(Figures 31-3 and 31-4). If the periodontal bone loss is severe and
the bone level cannot be visualized on regular bite-wing radiographs, films can be placed vertically to cover a larger area of the
jaws (Figure 31-5). More than two vertical bite-wing films might
be necessary to cover all the interproximal spaces of the area of
interest.

Amount. Radiographs are an indirect method for determining

the amount of bone loss in periodontal disease; they image the
amount of remaining bone rather than the amount lost. The
amount
of bone lost is estimated to be the difference between the
physiologic bone level and the height of the remaining bone.
The distance from the CEJ to the alveolar crest has been analyzed by several investigators.12,14,27 Most studies, conducted in
adolescents, suggest a distance of 2 mm to reflect normal
periodontium; this distance may be greater in older patients.

Distribution. The distribution of bone loss is an important

diagnostic sign. It points to the location of destructive local
factors

BONE DESTRUCTION IN
PERIODONTAL DISEASE
Early destructive changes of bone that do not remove sufficient
mineralized tissue cannot be captured on radiographs. 3,4,25 Therefore slight radiographic changes of the periodontal tissues suggest
that the disease has progressed beyond its earliest stages. The
earliest
signs of periodontal disease must be detected clinically.

Bone Loss
The radiographic image tends to underestimate the severity of bone
loss.28,32 The difference between the alveolar crest height and the
radiographic appearance ranges from 0 mm to 1.6 mm,27 mostly

Figure 31-2 Comparison of long-cone paralleling and

bisectionof-the-angle techniques. A, Long-cone paralleling
technique,
radiograph of dried specimen. B, Long-cone paralleling
technique,
same specimen as A. Smooth wire is on margin of the facial
plate
and knotted wire is on the lingual plate to show their relative
positions. C, Bisection-of-the-angle technique, same
specimen as
A and B. D, Bisection-of-the-angle technique, same
specimen.
Both bone margins are shifted toward the crown, the facial
margin
(smooth wire) more than the lingual margin (knotted wire),
creating the illusion that the lingual bone margin has shifted apically.
(Courtesy Dr. Benjamin Patur, Hartford, CT.)

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